When to push with epidural?

amberm72 · May 20, 2001

So now that everyone thinks I'm a narc--there are some issues I should clarify. I know my sweet Alisa personally and have worked with her closely for awhile now. It's true that I am new to the board and stumbled on my dear friends board and I thought I would rib her a little and give her heck for saying that she lies to physicians. Alisa is a very ethical and loyal person and nurse and at no time would she ever compromise pt. care with lying etc... to get what she wanted. There is one nurse anesthetist in particular that refuses to give epidurals to women that are not a good 4 cms and complains when the doctors "make" her do it because the patient is out of control. It is my fault for falsely posting false information intentionally to give Alisa a bad time and therefore misleading all of you. To be honest, I didn't think that anyone would respond--boy was I wrong. I would never "narc" anyone out unless I thought someones life was at steak. My goal is to keep my own patients safe and practice nursing ethically while being a patient advocate--I don't want to have to worry about how my fellow nurses practice as well, I just want to be able to communicate and bounce ideas off my fellow co-workers and hopefully better the nursing practice as a whole. I hope this clarifies this issue for you all. Please forgive my for misleading you all. I will humbly leave my honest opinion from now on. Please respond--comments are welcome

AlisaL&D · May 20, 2001

Well this issue of lying is becoming blown out of proportion. I should explain myself better. I certainly understand the risk of giving an early epidural with inadequate fetal descent which could result in acynclitic descent, and also the risk of placing one with a poor contraction pattern. Having said that, in the past, I have worked in a facility where things are not "black and white" and the "gray" areas of nursing face us each day. I resent making a woman wait until four centimeters because that is that physician's or CRNA's "magic number", especially on an induction that we will augment anyway. We have CRNAs that refuse an epidural, despite the doctors orders until they are at least 4cms, despite a low station, gross rupture or a woman that is bearing down on a cervix causing edema because she is screaming out of control. You may bash me but I occasionally will tell them they are 4 cms in order to get the epidural, but to the doctor I let them know the situation. I have also worked with physicians that are so poorly trained and barely functional that if I don't manage the case for them, they will screw it up....for example, "a physician that will come into a room where fetal tones are stuck in the 60's, the mother is screaming, and his priority of care centers on asking me when the woman last voided and what her most recent BP was. I want to tell him to put a sterile glove on, do some scalp stim, and shut up. I do agree that a labor will face the lowest risk of additive complications if allowed to progress naturally, but many women need an epidural early in order to cope, plain and simple. To this end, I advocate for them, and my outcomes are positive. Enough said.

amberm72 · May 20, 2001

Hey!

Perfectly said my friend!! Any facility would be very fortunate to have you on their staff!! You are a wonderful nurse and friend for that matter--and I hope that I can incorporate all that I have learned from you into my nursing practice. I love ya and please keep tickling the brains of those that have been L&D nurses forever and those that are just getting their toes wet! I know you will continue to enlighten us all!

Ambor! (and Tuckie)!

Q. · May 20, 2001

Somehow this discussion turned into the twilight zone somewhere - both of you gals lost me in your deep, intertwined discussion...of....something.

My eye is even twitching.

**canoehead, BSN, RN** · Jun 22, 2001

Well you guys really know how to stir up a storm. Truthfully, if there are any night folks out there, we pretty much manage the labors ourselves. I know when I call a doc in the middle of the night I'd better have a good idea of what is needed, or may end up with a Tylenol order. So, we all know what has worked for us in the past, and read the journals, and pretty much call with info we think is pertinent. We have a lot of influence there.

That said, having managed the labor to 1+ stn, and the doc says don't call til she's fully, what do you do when he says " I'm on my way, don't let her push" (!) knowing the guy has just been sound asleep and lives a half hour away. Any thoughts?

woopcrane · Jun 23, 2001

WOW - just read this thread - brings up a lot of issues doesn't it?

So here is my 2 cents

As we are learning more about the second stage of labor, we have discovered that often there is a latent phase, usually soon after 10 cm when the body slows contractions and the women takes a rest. Many do not immediately even feel like pushing - epidural or not. This phase can last up to 30 min.

Your nurses who suggest the squat position are right on target - it opens the pelvis and assists with decent. If the epidural is a "heavy" one, this is the time to slow it down so the woman can feel her contractions to coordinate the pushing, or GET into the squat. THIS IS NOT TO SAY LET IT COMPLETELY WEAR OFF!!!

Women with epidurals need active coaching to coordinate their pushing efforts. I find it usually takes about 30 min or so to really get a woman into coordinated effective pushing.

Hopefully the count down clock starts when the woman really starts to push effectively - not when she hits 10 CM.

As for lying.

As noted above, this is not professionally acceptable.

Besides being dishonest about a patient's true condition, it is a return to the old subservient doctor nursey games. As a professional RN, you do not need to lie - tell it how it is, that the person is pushing well, the head is descending, and you anticipate a lady partsl delivery -

Innercity Nurse Midwife with 14 years as a labor&delivery nurse